Provider Demographics
NPI:1578613071
Name:CHILDERS, SHANNON OUTEN (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:OUTEN
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16367
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28816-0367
Mailing Address - Country:US
Mailing Address - Phone:828-252-8957
Mailing Address - Fax:828-255-8028
Practice Address - Street 1:1201 PATTON AVE
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-2707
Practice Address - Country:US
Practice Address - Phone:828-252-4878
Practice Address - Fax:828-252-4103
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA856363AM0700X
NC101430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical